Experiences of elderly men regarding acute myocardial infarction

Abstract

Objective:

To analyze the experiences of elderly men in relation to acute myocardial infarction before, during and after clinical diagnosis.

Methods:

This is a descriptive and qualitative study. The research was carried out in two hospitals located in the municipality of Feira de Santana, Bahia, Brazil. Elderly men with a confirmed medical diagnosis for acute myocardial infarction participated in the study. Data were collected using the interview technique, guided by a semi-structured script. All speeches were recorded with authorization, transcribed in full and systematized through the Discourse of the Collective Subject. The interpretation of the data was supported in the scientific literature about acute myocardial infarction and in the theoretical framework of gender from the perspective of hegemonic masculinity.

Results:

The Discourse of the Collective Subject showed that the experiences of elderly men in relation to acute myocardial infarction before, during and after diagnosis were impregnated with markers of hegemonic masculinity, which prevented them from recognizing the severity of signs and symptoms and the need to seek care. The statements reveal that the entire process of illness and post-diagnosis therapy was marked by emotional conflicts, since elderly men had to adopt lifestyle changes and recognize their vulnerability.

Conclusion:

The findings stand out for the relevance of health professionals to understand and consider gender markers during prevention and treatment of cardiovascular diseases, considering that they strongly influence the health care of elderly men.

Keywords
Myocardial infarction; Gender analysis in health; Men's health; Health care

Resumo

Objetivo:

Analisar as vivências masculinas de idosos em relação ao infarto agudo do miocárdio antes, durante e depois do diagnóstico clínico.

Métodos:

Trata-se de um estudo descritivo com abordagem qualitativa. A pesquisa foi realizada em dois hospitais localizados no município de Feira de Santana, Bahia, Brasil. Os participantes foram homens idosos com diagnóstico médico confirmado para infarto agudo do miocárdio. Os dados foram coletados utilizando-se a técnica da entrevista, guiada por um roteiro semiestruturado. Todas as falas foram gravadas mediante autorização, transcritas na íntegra e sistematizadas através do Discurso do Sujeito Coletivo. A interpretação dos dados respaldou-se na literatura científica acerca do infarto agudo do miocárdio e no referencial teórico de gênero, a partir da perspectiva da masculinidade hegemônica.

Resultados:

O Discurso do Sujeito Coletivo evidenciou que as vivências dos homens idosos em relação ao infarto agudo do miocárdio antes, durante e depois do diagnóstico estiveram impregnadas por marcadores da masculinidade hegemônica, os quais os impediram de reconhecer a gravidade dos sinais e sintomas e a necessidade de buscar pelo cuidado. As falas revelam que todo o processo de adoecimento e terapêutica pós-diagnóstico foi marcado por conflitos emocionais, visto que os idosos tiveram que adotar mudanças no estilo de vida e reconhecer a sua vulnerabilidade.

Conclusão:

Os achados despontam para a relevância dos profissionais de saúde compreenderem e considerarem os marcadores de gênero durante as ações de prevenção e tratamento das doenças cardiovasculares, tendo em vista que estes influenciam fortemente no cuidado à saúde dos homens idosos.

Descritores
Infarto do miocárdio; Análise de gênero na saúde; Saúde do homem; Atenção à saúde

Resumen

Objetivo:

Analizar las vivencias masculinas de ancianos respecto al infarto agudo de miocardio antes, durante y después del diagnóstico clínico.

Métodos:

Se trata de un estudio descriptivo con enfoque cualitativo. La investigación fue realizada en dos hospitales ubicados en el municipio de Feira de Santana, estado de Bahia, Brasil. Los participantes fueron hombres ancianos con diagnóstico médico confirmado de infarto agudo de miocardio. Los datos fueron recopilados utilizando la técnica de entrevista, conducida con guion semiestructurado. Todas las conversaciones fueron grabadas con autorización, transcriptas totalmente y sistematizadas a través del Discurso del Sujeto Colectivo. La interpretación de los datos se respaldó en la literatura científica sobre infarto agudo de miocardio y en el marco referencial teórico de género, a partir de la perspectiva de masculinidad hegemónica.

Resultados:

El Discurso del Sujeto Colectivo reveló que las vivencias de los hombres ancianos respecto al infarto agudo de miocardio antes, durante y después del diagnóstico estuvieron impregnadas de marcadores de masculinidad hegemónica, los que impiden que puedan reconocer la gravedad de los signos y síntomas y la necesidad de buscar ayuda. Los relatos exponen que todo el proceso de enfermedad y terapia posdiagnóstico fue marcado por conflictos emocionales, dado que los ancianos tuvieron que adoptar cambios en su estilo de vida y reconocer su vulnerabilidad.

Conclusión:

Los descubrimientos recuerdan la importancia de que los profesionales de la salud comprendan y consideren los marcadores de género durante las acciones de prevención y tratamiento de enfermedades cardiovasculares, teniendo en cuenta que estos influyen fuertemente en el cuidado de la salud de los hombres ancianos.

Descriptores
Infarto del miocardio; Análisis de género en salud; Salud del hombre; Atención a la salud

Introduction

Cardiovascular diseases, including acute myocardial infarction, present themselves as an important public health problem. They are one of the main causes of male morbidity and mortality worldwide, with emphasis on elderly individuals, which is considered a risk group for this type of pathology. Considering that men are the most affected by heart diseases and that the aging process intensifies the male predisposition to illness, it is urgent that health professionals recognize the impact of gender markers for the effectiveness of care provided to this public.

In Brazil, the number of elderly people has grown considerably. It is estimated that in 2025 it will be the sixth largest elderly population in the world, with 32 million people in this age group.⁽¹⁾ Aging, in turn, is related to the occurrence of chronic non-communicable diseases as a consequence of inappropriate habits acquired throughout life, among which systemic hypertension, diabetes mellitus, and obesity stand out.⁽²⁾ These diseases considered prevalent among elderly men are directly related to the occurrence of acute myocardial infarction.⁽²⁾

Male mortality rates from this cause are alarming in the country. From 2008 to 2016, 21,398 deaths were reported, of which 13,587 were men, which represents 63.4% of cases.⁽³⁾ It is relevant to address that acute myocardial infarction in men is related to social gender issues, which must be understood in an attempt to minimize the damage to this population. Values inherent to hegemonic masculinity, such as virility, strength and honor, have directed male behavior towards toxic and risky practices, especially in relation to their health.⁽⁴⁾ The conception based on hegemonic masculinity has repercussions on the self-care in health provided by men, persisting in the non-demonstration of signs of fragility, understanding it as something specific to women, which affects their health condition.⁽⁵⁾

This study aims to analyze the experiences of elderly men in relation to acute myocardial infarction before, during and after clinical diagnosis. It also proposes to subsidize the construction of strategies for the prevention of male health problems and to contribute to the minimization of the impacts resulting from hospitalizations for cardiovascular diseases.

Methods

This is a descriptive and qualitative study carried out in two hospitals (one public and one private) located in the municipality of Feira de Santana, Bahia, Brazil. Participants were 13 elderly men with a confirmed medical diagnosis for acute myocardial infarction. Those who were clinically and/or emotionally unstable to participate in data collection were excluded according to the assessment carried out by health professionals linked to services.

Participant approach was favored by previous insertion of the main researcher in the field, since he also acted as an internship preceptor nurse in both hospitals. Thus, men who met the inclusion criteria were informed about the relevance and objectives of the study, the voluntary nature of participation, the possibility of giving up at any time, the guarantee of anonymity and confidentiality of information, among other ethical aspects recommended by Resolution 466/12 of the Brazilian National Health Council (Concelho Nacional de Saúde).⁽⁶⁾ There was no refusal by the guests, and all signed the Informed Consent Form. The Research Ethics Committee of Faculdade Nobre de Feira de Santana approved this study, under Opinion 2.511.516. It met the criteria of the Revised Standards for Quality Improvement Reporting Excellence, SQUIRE 2.0.⁽⁷⁾

The data were collected from February to March 2018 by the main researcher, who is trained to use the interview technique. The interview was guided by a semi-structured script addressing, in addition to the sociodemographic aspects, the following guiding question: how were your experiences in relation to acute myocardial infarction before, during and after clinical diagnosis? The interviews lasted an average of 30 to 60 minutes and took place individually in a private room provided by the hospitals, taking into account the clinical particularity of each participant. It is worth mentioning that the number of respondents was not previously defined, which was delimited based on the saturation of information.⁽⁸⁾

All speeches were recorded with authorization, transcribed in full with the support of a text editing program and identified by letter H and the order number of the interviews. At the end of the organization process, the textual corpus was validated by the respondents, who signed the letter of rights session, authorizing its use for analysis.

Then, the narratives were systematized using the Discourse of the Collective Subject (DCS) method. DCS enabled the construction of synthesis discourses that represent the community. For this, the following methodological figures were used: 1) Central idea (CI): name or expression that allows to summarize the essence of what was said; 2) Key expression (KE): exact clipping of the participant's speech.⁽⁹⁾ This process was carried out with the support of NVIVO^®11, created to favor the organization of qualitative data. It is noteworthy that during the organization and analysis of the speeches, peer checking was carried out, which converged in relation to the interpretation of the statements. Data analysis, in turn, was supported in the scientific literature about acute myocardial infarction and in the theoretical gender framework from the perspective of hegemonic masculinity.⁽⁴⁾

Results

Elderly men (between 62 and 72 years old) with a confirmed medical diagnosis for acute myocardial infarction participated in the research. Most of them were characterized as mixed-race, with low education, were retired, but also engaged in work activities related to commerce, agriculture and other autonomous activities, with family income of up to four minimum wages, and had an average of three children. The experience of acute myocardial infarction was revealed by four central ideas described below:

Central idea synthesis 1: Experiencing risk factors and not recognizing the signs and symptoms of acute myocardial infarction

The speech revealed that men showed risk behaviors for acute myocardial infarction in their daily lives expressed by physical inactivity, smoking, alcohol consumption, unhealthy food intake and exposure to stress in the workplace. In view of the initial manifestations of the disease, there was no recognition of them as a heart problem, which are associated with other morbidities.

I did not practice physical activities. I always smoked and ate fatty foods, spent the whole day making exaggerated physical effort at work and lived stressed. When I got home, just want to lie on the couch and watch TV. On weekends I liked to go out with friends to eat and drink everything I wanted. Suddenly, I started to feel chest pains that disappeared with time, but I didn't care. I thought it could be bronchitis or stomach problems because I was coughing and with a lot of gas. I even bought a medicine to try to relieve what I was feeling. I didn't imagine what was happening, I didn't know the symptoms of a heart attack (DCS H1 H3 H4 H5 H6 H7 H8 H 9 H11 H12 H13).

Central idea synthesis 2: Progressive signs and symptoms and denial of illness

Progressive appearance of signs and symptoms manifested in breathing difficulties during walking, paresthesia of the upper limbs and back pain was revealed in the collective discourse. Moreover, the survey participants revealed that, despite intensification of angina, they did not seek care at the health service considering their condition as a strong man.

The time passed and I was presenting other annoyances. Whenever I went up a slope, I would lose my breath. I started to feel tingling in my left arm and back pain. The chest pain was weak, then it got worse. Even so, I didn't go to the health clinic, because I tried to support it. All this because I am a strong person, I felt like an iron man and I would not give myself up to a little pain. They say the man doesn't cry, but the pain was so unbearable that it was beyond my strength and I cried (DCS H2 H3 H4 H5 H7 H8 H9 H11 H12 H13).

Central idea synthesis 3: The event of acute myocardial infarction and access to service

The male search for health care took place in a solitary way, motivated by the intensification of precordial pain, a condition that led men to interrupt work activities and to fear of death. The speeches also reveal that the attendance of men in the emergency department occurred quickly, considering the severity of their health status.

When I was at work the pain became unbearable, causing me to stop working. That was when I decided to seek medical help for fear of dying and for not wanting my family to know about it. I drove to the emergency service. When I arrived at the hospital, the pain completely overwhelmed me. My heart was out of control, like it was being crushed. I felt uneasy, I was sweating cold, I had shortness of breath, as if it were a choke, I vomited, I weakened, losing my body's resistance and my senses. Soon I was treated, medicated and sent for exams. After the results, the doctors diagnosed me with a heart attack. If I had taken longer to seek care I would not have resisted (DCS H2 H3 H4 H5 H7 H8 H9 H11 H12 H13) (DCS H1 H3 H4 H5 H6 H7 H8 H 9 H11 H12 H13).

Central idea synthesis 4: Repercussions of acute myocardial infarction

Acute myocardial infarction brought repercussions for men regarding their autonomy expressed in their family members' prohibition on the adoption of habits inappropriate to their health. Furthermore, the speeches point out that the research participants started to present psychological problems and fear of death.

When I was diagnosed with a heart attack, I started to be watched by my daughters and my wife. They prohibited me from smoking, drinking and eating things I liked. He was always afraid, afraid to get sick again. I developed panic syndrome, became depressed and lost hope of living (DCS H1 H2 H3 H4 H5 H6 H7 H8 H 9 H10 H11 H12).

Discussion

The speeches reveal that the daily pre-illness of the elderly men surveyed was marked by the experience of stress in the workplace, physical inactivity, smoking, alcoholism and unhealthy food intake. These behaviors are identified in the literature as risk factors for heart disease. The male population was the most affected by carelessness in relation to their health,⁽¹⁰⁾ a characteristic built throughout life and which remains in old age. This trend is confirmed by national and international data, and it is possible to notice that cardiovascular diseases represent the second cause of death among men.^(11,12)

These morbidity and mortality data may be related to the gender category, allowing to understand the process of male illness, since it guides the attributes and behaviors of men and women in our society.^(4,13) Men, from an early age, are assigned roles that are anchored in honor, strength, power and family provision, characterizing a model of masculinity that, despite being hegemonic and socially accepted, is not universal.⁽¹⁴⁾ These constructs make elderly men often neglect their health, since they have been culturally directed to believe, throughout their lives, that they are immune to any pathological process. So, when they have some kind of change in health, they tend not to worry, practicing self-medication in an attempt to solve the problem alone.⁽¹⁵⁾

According to the discourse of males, the progression of the illness was marked by dyspnea and increased precordial pain when performing simple activities such as going up and down stairs. National and international studies reveal the importance of recognizing the signs and symptoms of infarction, such as precordial pain, breathing difficulties, nausea, vomiting and sweating.^(16,17) Despite the importance of early identification of these signs, the study reveals that elderly men did not seek care in health services, anchoring on the concepts of strength and not fragility. This attitude is also evidenced in a study carried out with men from northeastern Brazil. They claimed that they did not seek medical attention because they understood that the search for health care is a ratifying of their condition of weakness, starting to adopt behaviors of invulnerability that imply a greater exposure to risk situations.⁽¹⁸⁾

Considering this conception, the collective discourse showed that the respondents delayed the search for medical care, seeking the health service only through intensification of pain to the point that it manifests itself intolerably. Even so, the decision to seek professional help was permeated by risky behavior. Elderly people, despite showing classic symptoms of acute myocardial infarction, chose not to expose the problem, driving to the hospital, which compromised not only their own safety, but that of other people.⁽¹⁹⁾

The conduct of elderly men in the research reflects the strong influence of gender stereotypes rooted in patriarchal society, which drive the male understanding that illness and the feeling of pain should not be externalized. They represent signs of weakness and fragility, characteristics incompatible with the hegemonic figure of the strong and invulnerable man.⁽²⁰⁾ It is precisely because of the predominance of conceptions like these that, in general, men are more affected by severe health conditions and die more than women from the main causes of death. They do not use primary care services, entering the health system for specialized care, usually with a serious health problem already installed.⁽¹¹⁾ Epidemiological data corroborate these findings as they associate the male search with high complexity services, often due to the need for access to hemodynamics for catheterization, stent placement and myocardial revascularization. These procedures that have a significant financial impact on public health services.⁽¹⁰⁾ Furthermore, it is urgent that measures be taken to prevent or better manage heart diseases for men, thus preserving the life and economy of the country.

As described in our study, the scientific literature also points out that the marker “time” is essential for patient survival, so that the period between the onset of symptoms and care must be as short as possible.⁽²¹⁾ A study carried out in North America showed that the faster the myocardial reperfusion, the better the cardiac function after the procedure, as well as the lower the chances of reinfarction.⁽²²⁾ On the other hand, a research conducted in the Netherlands showed that patients who waited longer for reperfusion had a high mortality rate.⁽²³⁾ It is noteworthy, however, that in addition to the late male recognition of the need to seek health care, other factors can also be an impediment to agility and efficacy in treatment such as overload and lack of necessary resources in public health institutions.⁽³⁾

From the collective discourse, it was possible to infer that in addition to the emotional conflicts experienced by individuals at the time they are having a heart attack, several other psychological repercussions are manifested in the daily lives of men after acute myocardial infarction. Among them are the fear of falling ill again, depressed mood and lack of hope in relation to life, data corroborated in studies conducted in Italy and Brazil.^(24,25) Feelings expressed through the narratives reflect the change in family dynamics imposed by the medical diagnosis, placing the man in a position, hitherto unknown, of submission and obedience to the female figures represented by wives and daughters.

Another element that draws attention in male speeches is that, despite being over 60 years old, the elderly men reported being in the work environment when they manifested the first symptoms of infarction. This suggests continuation of occupational activities even after retirement. This is the reality of most of Brazilian individuals, which generally changes the nature of the bond, migrating from formal work (if retirement has occurred for length of service) to informal work (which can be maintained when retirement was due to minimum age).⁽²⁶⁾ It is worth mentioning that, even after the Pension Reform, compulsory retirement remained at 75 years old in the form of Complementary Law 152/2015,⁽²⁷⁾. This fact leads us to infer that elderly men suffered interruption of occupational activities due to acute myocardial infarction.

From this perspective, it is believed that, for the elderly men in the study, heart disease, in a way, was accompanied by male essence loss. In addition to the impairment of work capacity, the condition to achieve a good prognosis was linked to deconstruction of invulnerability and abandonment of habits considered harmful such as smoking and alcoholic beverage consumption. Since it is a chronic condition, therapeutic regimens for cardiovascular diseases require great effort to change lifestyle. The health education strategies developed by nurses are essential, which must understand and consider how gender issues impact on men's health care.⁽¹¹⁾ Furthermore, due to their proximity to users, female nurses are able to detect toxic gender and clinical markers that precede heart disease early.⁽²⁸⁾

Professionals can act preventively both in the community and in the male work and leisure environment through health education, considering the low male demand for primary care services.⁽¹⁶⁾ In the hospital, nurses, when identifying worsening of the disease, must also consider gender markers when promoting health education aiming at better treatment adherence.^(29,30)

The results indicate potential for understanding masculinity ideals from the perception of elderly men affected by acute myocardial infarction. They should be valued in planning actions and public policies aimed at the health of this population group. Investigation on masculinity characteristics must be institutionalized in the clinical practice of health services, especially in primary care, the ideal gateway for SUS and where the prevention of risk factors and cardiovascular disease should be prioritized.

It should be noted, however, that the research has limitations due to the study design adopted. Convenience sampling, even considering well-defined criteria for the selection of participants, may have excluded the possibility of including men with divergent perceptions from those analyzed in this study. In addition, the evidence produced must be understood with caution, considering the small number of elderly men participating. Moreover, the short period of collection, combined with the research field in only two units, made the composition of probabilistic sampling difficult, which would enable more robust analyzes of the researched phenomenon.

Conclusion

DCS showed that the experiences of elderly men in relation to acute myocardial infarction before, during and after diagnosis were impregnated with markers of hegemonic masculinity, which prevented them from recognizing the severity of signs and symptoms and the need to seek care. The statements reveal that the entire process of illness and post-diagnosis therapy was marked by emotional conflicts, as men had to adopt lifestyle changes and recognize their vulnerability. The findings stand out for the relevance of health professionals to understand and consider gender markers during the actions of prevention and treatment of cardiovascular diseases. Such gender markers strongly influence men's health care.

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Publication Dates

• Publication in this collection
  05 May 2021
• Date of issue
  2021

History

• Received
  22 Apr 2020
• Accepted
  03 June 2020